7th Annual Autism Summer Institute
July 28 - 30, 2008 8:30 am – 4:00 pm
First Name :
Last Name :
School/Employer:
Work Phone:
City :
Home Phone:
County:
Email:
*Are You Out-of-Field?
YES/NO
*Out-of-Field refers to a teacher in a district school system assigned to teach outside the area in which he or she was certified
Job Title:
Please Select
Elem. Teacher (K-5)
MS Teacher (6-8)
HS Teacher (9-12)
Multi Level Teacher
Itinerant Teacher(K-12)
Pre-K Teacher
Student (PK-12)
Family Member
Paraprofessional
Therapist (OT/PT/SLP)
ESOL Teacher
Title 1 Teacher
District Program Staff
Principal/A.P.
Other School Prof.
Behavior Specialist
Social Worker
Psychologist
Counselor
Nurse
FDLRS Staff
Project Staff
Other Agency Staff
Undergraduate Student
Graduate Student
In State Univ. Staff
Out of State Univ.Staff
Other School Support
Bus Driver/ Aide
Substitute
Private Consultant
DOE Staff
Preservice Teacher
Class Type:
Please Select
General Education
ESE - Not Autism
Autism
N/A
School Type:
Please Select
Private
Charter
Public
N/A
Certification:
Please Select
General Education
Varying Excep.
Other ESE
Not Certified
Not Applicable
What is your current school grade?
Select
A
B
C
D
F
Do you have an endorsement certificate in Autism ?
Y/N
Do you have an endorsement certificate in Severe and Profound disabilities ?
Y/N
If not, are you in the process of completing an endorsement certificate ?
Y/N
